Investigation of Depression - Essay Example

?Introduction Depression is a leading cause of disability worldwide (Gilbody, 2006). It is a frequent medical condition occurring in a significant percentage of the elderly population. Depression has long been associated with disability in the elderly population and also with a bevy of other health-related problems that bear upon a reduced quality of life. Smith et al report studies describing afflictions among 44% of nursing home residents and 24% of elderly in assisted living programs. Depression can exacerbate experienced pain and along with anxiety extend chronic pain syndrome (Smeeding et al, p. 824). This proposal outlines an intervention plan and its evaluation process. The intervention plan is depression screening for the elderly promoted as a public policy model that seeks to combine and integrate mental health and primary medical services in one delivery intervention framework. The essential elements of the framework will be outlined and addressed. A scheme of integrating depression screening in primary nursing gerontology care will be proposed by reviewing studies dealing with depression in the elderly population and outlining how mental health can be integrated in primary care by suggesting specific training processes for nurses that will enable them to identify and address depression and its conditions in the elderly. Forming part of the public policy intervention plan, evaluation of the proposal will be addressed along with its application to the intervention scheme. Evaluation will be a repeated-measures design for both the nursing population under training and the client population. Limitations will be discussed as well as how the public policy project may be sustained over time. Public policy models entail changes not in one institution but structural changes across the larger model of social delivery processes affecting the wider population. The elderly population will be increasing at greater rates over the next two decades. The current public political climate reflects an increasing unwillingness of local governments to improve responsibility for the safety net provisions required by the elderly. Public policy must be influenced to standardize an intervention framework that would integrate depression screening into primary general care for the elderly. This study will adapt an intervention model after a review of other integration models. It will then produce an evaluation strategy based on Reedy et al who demonstrate how program evaluation indicators could be adopted into implementation strategies as essential evaluation models of public health services. Literature Review Luchins argues that depression screening as far as it is operative as a quality indicator falls more under the purview of the administrator that that of the clinician. This would make depression screening a policy declaration or requirement mapped to some department goal. As a quality indicator and not as a practice guideline, depression screening would then demand a different kind of evidence evaluation, evidence based on a "chain of assumptions underlying the decision" for its use and application (p. 108). Quality indicators are administrative rules, or guidelines. They may affect different groups of patients than clinical screening for specific illnesses may affect. It has been demonstrated that physicians in general seem to ignore diagnostic information from other staff. Luchins main point is that depression screening many not be effective in the absence of other interventions. The one intervention in which it has shown to be effective is that of collaborative care (Gilbody). Luchins view of collaborative care comprises three elements. They are a case manager, the primary care physician, and input from a specialist (p. 111). A more adaptable view of the model explains collaborative care as structured where by nonmedical specialists play a greater role in augmenting primary care (Gilbody). The management of depression in primary care has proven evasive (Seekles, 2009). Seekles et al proposes a stepped care model in which all patients will receive low intensity evidence-based treatment. If there is no appropriate response, then the patient steps up to higher intensity treatment. This treatment regimen is managed by a paraprofessional operating as the care case manager specializing in psychiatric problems for the primary care clinic. The study conducted by Seekles et al involved patients with minor and or major depression and anxiety disorders. The step wise intervention model consisted of 4 steps of which the first was Watchful Waiting by which symptoms are viewed for a period of four weeks. If anxiety/depression symptoms continue, the second step, Guided self-help, is entered. Problem solving treatment is used whereby the patients is guided through a 6 week period self-help by motivation provided from the care case manager. The third step is Problem Solving Treatment (PST) which involves 5 sessions of short psychological interventions also conducted by the care case manager. If symptoms persist then the manager offers the patient a choice of pharmacotherapy and/or specialized mental health care at the fourth step. These regimens are provided by a GP or mental health care specialist. Seekles et al are presently conducting and evaluating this model in the Netherlands. Highlights of it are its integration of working relationships between nonmedical (nursing) specialists, primary care professionals, and secondary mental health specialists. Smeeding et al incorporated an Integrative Health Clinic and Program (IHCP) project that offered a non-pharmacologic biopsychosocial appraoch to the management of stress-related depression and anxiety on a group of patients presenting post-traumati stress disorder (PTSD) symptoms. They developed complementary and alternative medicine (CAM) modalities which, along with mind-body skill classes, combined social, spiritual, psychologic and physical care. CAM therapies uses defined relaxation techniques and modalities. They comprise a holistic umbrella involving a group of services organized into classes that cover 10 nonpharmacological mind-body skills and CAM therapies. Some of the class therapies include acupuncture, aquatic bodywork, _qigong exercises, medical hypnosis, mindfulness meditation groups, tobacco cessation program, and an integrative weight management program. The IHCP project method highlights the integrative approach of the present proposal whereby the modalities specifically offered a synergistic effect that promoted self-efficacy, "internal locus of control" to practice self-management techniques of pain. Integrating physical care with mental care, the IHCP project employed holistic patient assessment from the intake provider that resulted in a treatment plan specifically addressed to the patient's needs. Retesting was provided after 6 months and then adopted annually. Specifically the IHCP patient assessment employed the Medical Outcomes Multidimensional Short Form 36 (SF-36), the Beck Depression Inventory (BDI), and the Beck Anxiety Inventory (BAI). The SF-36 is a self-report measure used to provide scores on standard and alternative treatment outcomes. The SF-36 provides scores for general health, physical functioning, role physical, bodily pain, mental health, role emotional, social functioning, and vitality. The Beck Depression Inventory measures the severity of depression, while the Beck Anxiety Inventory measures the severity of anxiety. The IHCP program involving veterans with PTSD symptoms also used the self-reporting numerical rating scale (NRS) to measure stress. IHCP is similar to cognitive behavior therapy (CBT) strategies in that it teaches how to "move negative thought patterns to positive." CBT involves recognizing irrational thought patterns and excising them for rational patterns of thought. IHCP teaches calming techniques, thought awareness, and using self-relaxation to promote self-efficacy and self-esteem. These techniques all fit under appreciation of mind-body connection concepts that allow rapid analysis and self-management of negative thoughts in ways that could manage pain and stress. An overall randomized controlled trial was not provided hence results were not considered in regard to internal and external validity (p. 834). Instead a quasi-experimental comparison design was used to yield valid answers about overall effectiveness about the clinical applications of IHCP. Under such limitations, results of the comparison design demonstrated that CAM therapies and mind-body skills did prove beneficial in the self-management of depression and anxiety. Anxiety yield control benefits through 24 months, while depression yield benefits through 12 months. Scores on the SF-36 also demonstrated appreciative benefits. There is evidence suggesting that nurses may have difficulty identifying depression in the elderly population (Smith, 163). Other studies identified it as one of least manageable illnesses among nurses. Smith et al highlight a program, Nurses as Advocates (Depression Training to Promote Nurses as Advocates for Older Adults) based on dispersal and use of a CD-based (compact disc) self-directed training module. The four-part digitized presentations with workplace application exercises prepared the nurse to understand, assess, and care for depression in older adults and explained the importance of collaboration. Together the program incorporated collaborative care principles of the Improving Mood--Providing Access to Collaborative Treatment care model (IMPACT). In a study Smith et al distributed the training package to a state wide population and surveyed responses from 250 participants. The survey demonstrated pronounced improved outcomes among the nurses for older adults with depression. It importantly showed the lowest mean score for making referrals to other services. Smith et al explained the rural background of the state did place some limit on psychosocial and medical supportive services, but that the mean of this score was still above the midpoint. Develop a conceptual and organizational framework for the use of depression screening. Conclusion The goal of this study is to adopt depression screening as for the older adult population (age > 65) as a public policy for Cambel Hospital and its two community health centers. As suggested by Reedy et al an overriding conceptual and organizational framework mission statement was adopted. The mission was to integrate depression screening for the elderly into the primary medical services programs. The mission was based on the researched concept that structured collaborative care involved integrating the role of nonmedical specialists, i.e. nurses, in servicing mental illness in primary care settings. Several elements were fit into the plan after a review of evidence based practices from the literature. The Nurses as Advocates consists of a four-part self-training CD module. This module should be explained with workshops describing demonstrating as many of the 10 nonpharmacological therapies used by the Integrative Health Clinic and Program (IHCP) project. The IHCP has worked effectively in treating nonmalignant depression and anxiety with complementary and alternative medicine regimens. Hence Phase I of the plan involves training (through workshops and the self-training CD) all intake and triage nurses on depression and the elderly. Nurses should also be trained for familiarity with the Geriatric Depression Scale, a good and easily administered test for depression and anxiety for the elderly. Advance practice nurses can receive a more specialized set of workshops dealing with cognitive behavior therapy. These nurses should be prepared to take up psychosocial case management roles as defined in Seekles et al. Hence a two-level tier of nurses will be formed, the intake nurses and the advance practice nurses. Initially empirical assessment of effectiveness must be obtained before efficiency can be indicated as part of program evaluation (Reedy et al). Collaboration is reached with all organizational stakeholders in Phase I of the program as to the program’s mission and also in order to understand program evaluation. After training, nurses will begin the program by assessing all elderly with the Geriatric Depression Scale. Objectives of the program will be measured by an indication which of the elderly were referred to step two of the program involving guided self-help, managed by the advance practice nurse. This program occurs in consort with the primary medical program of the elderly patient. Hence the most important initial measurement of the program would indicate that nurses have referred patients to step two, comprising involving with the advance practice nurse. Involvement of the other stakeholders will be a main focus for insuring program sustainability. These stakeholders are the other medical staff, the physicians and the consulting psychiatrists. Their non-participation would comprise the programs major negative outcome. As the program goes through its first phase, involving the training, and the second phase, involving implementation, workshops are held with this other relevant staff to involve them in program evaluation, and to build up the necessary support and avoid the negative outcome of non-participation. References Gilbody, S., Bower, P., Fletcher, J., Richards, D. and Sutton, A.J. (2006). Collaborative care for depression: A cumulative meta-anaysis and review of longer-term outcomes. Archives of Internal Medicine, 166, 2314-2321. Luchins, D.J. (2010). Depression screening as a quality indicator. Mental Health in Family Medicine, 7, 107-13. Reedy, A.M., Luna, R.G., Olivas, G.S., and Sujeer, A. (2005). Local public heath performance measurement: Implementation strategies and lessons learned from aligning program evaluation indicates with the 10 essential publich health services. Journal of Public Health Management Practice, 11(4), 317-325. Seekles, W., van Straten, A., Beekman, A., van Marwijk, H., Cuijpers, P. (2009). Stepped care for depression and anxiety: from primary care to specialized mental health care: a randomised controlled trial testing the effectiveness of a stepped care program among primary care patients with mood or anxiety disorders. BMC Health Services Research, 9(90), 1-10. Smeeding, S.J.W., Bradshaw, D.H., Kumpfer, K., Trevithick, S., and Stoddard, G.J. (2009). Outcome evaluation of the Veterans Affairs Salt Lake City Integrative Health Clinic for chronic pain and stress-related depression, anxiety and post-traumatic stress disorder. Journal of Alternative and Complementary Medicine, 16(8), 823-835. Smith, M., Johnson, K.M., Seydel, L.L., Buckwalter, K.C. (2010). Depression training for nurses: Evaluation of an innovative program. Research in Gerontological Nursing, 3(3), 162-175. Read More